MedicaidAdministrativeMedium impact
Approved and Authorized Representative Forms
Illinois Medicaid - HFS·IL · Geriatrics·Provider Notice
Effective date
Nov 2, 2018
We identified it
Jun 20, 2026
Summary
Effective immediately, healthcare providers must complete and submit two new DHS forms before acting as legal representatives for residents in Medicaid applications or appeals. Form IL 444-2998 is required for benefit applications, and Form IL 444-0960 is required for coverage denial appeals.
Action Required
Immediately: Long-term care providers must complete DHS form IL 444-2998 (Approved Representative Form) before applying for Medicaid benefits on behalf of residents, and form IL 444-0960 (Authorized Representative Form for Appeals) before appealing coverage denials. Forms must be signed by both applicant and representative, uploaded to ABE system or mailed per form instructions. Retain copies of all submitted forms. Contact Bureau of Long Term Care at 1-844-528-8444 with questions.